Evaluating the Effectiveness of RPM Technologies in Medi-Cal Waiver Programs
California Association of Health Services at Home (CAHSAH) Foundation
The California Association for Health Services at Home (CAHSAH) Foundation, in collaboration with the California Department of Health Care Services (DHCS), Long-Term Care Division, introduced a remote patient monitoring program into multiple home health agencies (Accredited Home Health Services, Maxim Healthcare Services, Inc., Oxford HealthCare Services, Spirit Home Health Care, Alternative Home Care, Home Health Care Management, Inc., Oso Home Care, Inc., and Sutter VNA) to improve patient outcomes and reduce health care utilization.
The Remote Patient Monitoring (RPM) program utilized Intel’s Health Guide PHS6000 for daily monitoring of older adult health conditions and information exchange via e-mail messaging and video conferencing. The program targeted home health agencies that were administered, monitored, and/or overseen by the California Department of Health Care Services, Long-Term Care Division and utilized home care as an alternative to institutional care. These agencies provide either post-acute care or serve persons with disabilities and/or chronic disease.
- Reduce the number of avoidable 30 day readmissions, hospitalizations, and ED visits;
- Increase usability and acceptability of RPM system among patients, informal and formal caregivers;
- Improve patient functional status, quality of life, quality of care, and patient and caregiver attitudes, behaviors, and compliance;
- Make technologies available and reimbursable in Medi-Cal (Medicaid) Programs operating under waivers.
Approach:This program was a pilot and designed as a randomized, controlled trial where patients were randomized into either a six month home RPM intervention group or to usual care. To be eligible for the program, patients had to be Medi-Cal eligible (waiver), Age 40 or older, and meet one of the following conditions: diagnosis of CHF, COPD, or Diabetes; three or more co-morbidities; or three or more Emergency Department visits or hospitalizations over the last six months. Home health agency staff received training from Intel (now Care Innovations) and worked with an outside monitoring company that reviewed patient data obtained through the RPM device and contacted home health agency nurses as needed for patient follow-up. Patient data, such as weight and blood pressure, was obtained through the Intel Health Guide and peripheral devices. Additional data was collected through patient surveys. The program evaluation was intended to compare the experimental and control groups on a number of outcomes including: medical service utilization, cost of care, caregiver burden, clinical measures, and patient behaviors.
Results: The CAHSAH RPM project was terminated early because project staff were unsuccessful in enrolling sufficient participants. Lack of participants was due primarily to the inability to obtain sufficient home health agency partners as a result of limited Medi-Cal reimbursement. In addition, project staff found that a lack of incentives for both providers and patients resulted in weak enrollment. The project enrolled 15 patients in the intervention group and 12 in the control group prior to project termination.
Patient Recruitment and Enrollment:
- Target patients that can value most from the intervention. CAHSAH targeted the general Medi-Cal population at the start of the project, but was required to switch to a population that included patients that were only in the Medi-Cal waiver program. The Medi-Cal waiver patient population generally has chronic long-term care conditions that are not intermittent as with CHF and COPD patients. The waiver population was less likely to benefit from RPM in that this population often received hourly care and had a Licensed Visiting Nurse (LVN) in the home, obviating the need for remote monitoring.
- Match the technology to patients. The RPM technology must be compatible with patient needs and characteristics. The RPM device used in this initiative had an English only interface, which was incompatible with the needs of several home health agencies serving a largely Spanish-speaking population. In addition, the Medi-Cal waiver patients reported that the effort to enter results into the computer was burdensome for them.
Provider Engagement and Satisfaction:
- Make the startup process as smooth as possible for providers. Technology mishaps undermined provider's trust and interest in the program. The amount of time required to get started with the technology was also a project impediment.
- Consider providing incentives for providers. Programmatic difficulties (i.e., patient recruitment, technology issues) and added time constraints on agency staff caused the home health agencies to reconsider their involvement in the RPM program. Offering incentives to providers for their participation may help encourage agency participation and increase staff resolve to fully implement the program.
Project Management and Regulatory Compliance:
- Develop a sustainable equipment management and training process. Management of equipment varied by home health agency and was reported as a deterrent to patient and agency participation. Project staff indicated that provider training could be improved by changing the training schedule from a single day to multiple sessions with subsequent reinforcement.
- Approval of human subjects requirements can take longer than expected. In programs introducing RPM where human subjects are required, additional time should always be anticipated for Institutional Review Board (IRB) review and approval.
- Understand potential regulatory and reimbursement pitfalls before the project begins. In targeting a Medi-Cal waiver population, the program staff found out after the program had commenced that Federal Telehealth restrictions limited the patient recruitment pool. Participating home health agencies also found that Medi-Cal reimbursement was insufficient to warrant the use of RPM with their particular patient populations. Reimbursement levels by all payers must be reviewed carefully prior to implementation of an RPM program.